Robotic versus Standard Harvest of Deep Inferior Epigastric Artery Perforator Flaps: Early Outcomes

摘要

PURPOSE: Traditional deep inferior epigastric artery perforator (DIEP) flap harvest for breast reconstruction splits the anterior sheath of the rectus fascia from the perforating vessels to the deep inferior epigastric (DIE) vessel origin, weakening the primary strength layer of the abdominal wall, predisposing the patient to a bulge or hernia. Minimally invasive techniques are being developed to decrease abdominal wall morbidity.1,2 Previously published studies are limited to small case series and focus on technical descriptions of primarily unilateral flap harvest.3-5 We refined a transabdominal approach to robotic harvest of bilateral DIEP flaps with the da Vinci Xi Surgical System ®. This study describes our technique and examines early outcomes of robotic (rDIEP) compared with standard (sDIEP) harvest. METHOD: A retrospective cohort study was performed for patients who underwent bilateral rDIEP or sDIEP flap harvest at our institution between July 2021 and February 2022. Outcomes studied include abdominal wall morbidity, dissection time, total OR time, and length of stay (LOS). Technique Description Target perforating vessels are selected on preoperative imaging for their intramuscular course as this determines the fascial incision length.5 Following perforator dissection and suprafascial flap mobilization, robotic harvest of the DIE vessels is completed with the da Vinci Xi, utilizing its Firefly fluorescence imaging technology along with 2-3 doses of indocyanine green dye to provide a roadmap for safe and efficient intraabdominal dissection of the vascular bundles and their branches. After the DIE vessels are completely freed and all side-branches clipped, they are divided at their origins and exteriorized through the fascial incisions. While the microvascular anastomoses of the first flap are being performed, the superior extension of the DIE vessels on the 2nd flap is preserved to maintain circulation. RESULTS: Twenty-five patients were included (15 sDIEP (30 flaps), 10 rDIEP (20 flaps)) with no significant difference in patient age, BMI, or abdominal surgical history between cohorts. A greater number of perforators were included in the flap design for sDIEP compared to rDIEP (mean 2.65 vs 1.9, p=0.015). Mean fascial incision length in the rDIEP group was 4.55 cm while the mean pedicle length was 12.47 cm. This provided a mean ‘benefit’ as described by Selber et al. of an average 8.78 cm of spared fascial incision length.1,5 Mesh reinforcement of the abdominal wall was not required for any rDIEP; however, mesh was used in 12/15 sDIEP patients (p<0.001). Average robotic time was 173 minutes in the rDIEP group, without significant increase in overall case length (759 min vs 710 min, p=0.255). No pedicle or bowel injuries occurred during intraabdominal dissection. LOS was shorter with rDIEP (3.7 days vs 4.7 days, p=0.038). CONCLUSION: This is the largest reported cohort of bilateral rDIEP flap harvest and the first to compare outcomes to sDIEP. Our technique for rDIEP harvest is associated with decreased fascial incision length, elimination of the need for abdominal wall reinforcement and a reduction in LOS without significantly increasing operative time. REFERENCES: 1. Selber JC. The Robotic DIEP Flap. Plastic and Reconstructive Surgery. 2020;145(2):340-343. doi: 10.1097/PRS.0000000000006529 2. Manrique OJ, Bustos SS, Mohan AT, et al. Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: A Comparative Feasibility Study on a Cadaveric Model. J Reconstr Microsurg. 2020;36:362 – 368. doi: 10.1055/s-0040-1701666. 3. Sameer S, Spencera AB, Merisa Pipera M, et al. Laparoscopy allows the harvest of the DIEP flap with shorter fascial incisions as compared to endoscopic harvest: A single surgeon retrospective cohort study. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2021;74:1203 – 1212. doi:10.1016/j.bjps.2020.10.098 4. Daar DA, Anzai LM, Vranis NM, et al. Robotic deep inferior epigastric perforato